GW1-2021-07351_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. lq Q
4448A tJ I
ft. ft. 44
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case 'd wells OR LINER if a licable
CUMMINGS DEVELOPMENTS, INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 42 ft. 6 5/8 in. .188 G.STEEL
Company Name
_ f-1 16.INNER CASING OR TUBING"('eothermal closed400 )
2.Well Construction Permit#: ��� W LIU'"LI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ve.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in
_J Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residenfial Water Supply(shared) IS.GROUT
_J lrrl ation FROM TO NATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. ft. a'-,
_ Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
i Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAUEL`PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonriwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additiorial;shceN if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain sim,erc.)
Q ® ft. ft. •I
4.Date Well(s)Completed: '� 1`Z� Well ID# ft. t. 04A
`
5a.Well Location:
a. `- `_ -
`'k.ILI�1,1t ' 0.k` .1f S ft. ft.
Facility/Owne ame Facility ID#(if applicable)
4945 R 3 o a ft. ft. 2 �
Physical Address,City,and Zip G ft. ft. un
it
:PEA ��1 e_ g'g�t, a Z
1 � 21.REMARKS 10
County Parcel Identification No.(PIN) DVV
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certi6catio ufficient) D / 22. .
3&'o (0. 1�tN - 88� w n� 9-1-7,1
6.Is(are)the well(s) Permanent or Temporary azure crti ell Contractor Date
y signing this form,I hereby certify-that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) // Method of test: f 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /f%f,Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 .